Project Background: Across a variety of different health care payment systems, a minority of patients account for the majority of costs. Within VHA, the one-third of patients who have three or more chronic conditions account for two-thirds of costs. An even smaller group of patients is at near-term high risk of acute care, the single greatest driver of costs. Veterans cared for by primary care as part of VHA's Patient Aligned Care Teams (PACT) can be identified as at high risk of death or need for hospitalization using the Care Assessment Need (CAN) score. When these vulnerable patients experience gaps in care coordination, they are highly likely to experience negative outcomes. Although a variety of models of care to manage high-risk patients have been tested outside VHA, results have been variable. Within VHA, the Intensive Management Patient-Aligned Care Team (ImPACT) pilot and the five-site PACT Intensive Management (PIM) demonstration are providing insights into how PACT teams more generally can successfully care for high-risk patients. There remains an urgent need to develop better ways to implement coordinated care for these high-risk Veterans. Project Objectives: The proposed program aims to achieve the following impact goal: to improve care coordination and experience of care across settings for high-risk Veterans in PACT. This goal is aligned with Blueprint for Excellence transformational actions 1a (Coordination of Care in PACT for Complex Veterans), 2a (Triple Aim: Better Health, Care, and Value), 6e (Leverage Community Resources), and 8d (Collaborate with Community-based Organizations), and with MyVA focus areas 1: improving Veteran experience; 3: establishing a culture of continuous performance improvement, and 4: enhancing strategic VA- community partnerships. Within this program, Implementation Project 1 aims to disseminate strategies for coordination of care for high-risk Veterans via a distance-coaching strategy combined with an online toolkit. The quality improvement project aims to improve coordination between the Emergency Department (ED) and PACT by adapting and spreading a pilot-tested Computerized Patient Record System (CPRS)-based care coordination system for ED-PACT handoffs across all PACT sites in the VA Greater Los Angeles Healthcare System (VAGLAHS). Implementation Project 2 aims to improve coordination between high-risk Veterans and their home communities at hospital discharge by adapting an existing community alignment intervention. The implementation core focuses on assessing and improving organizational readiness for care coordination between PACT and other care settings; 2) core evaluation metrics reflecting patient-reported care experiences as well as electronic data; and 3) production of a combined care coordination toolkit across projects. Project Methods: The VA Offices of Patient Care Services, and Quality, Safety and Value will partner with QUERI to accomplish the proposed work. Implementation Project 1 involves 1) developing an online toolkit for care coordination in PACT, 2) piloting a distance coaching intervention at PACT sites, and 3) comparing the effectiveness of the online toolkit alone to the combination of the toolkit plus coaching. The quality improvement project will improve communication between the ED and the PACT team by a structured message being sent from the ED provider to the PACT nurse care manager, who then takes lead in triaging and arranging for appropriate care. Implementation Project 2 will involve 1) adapting a previously-tested community alignment intervention to the needs of VAGLAHS and Los Angeles community agencies for high- risk Veterans; 2) piloting the adapted intervention at VAGLAHS over a six-month period; 3) evaluating the full intervention at hospital discharge with 450 patients, half randomly assigned to the intervention and half to usual care. The implementation core will interface with each of the projects and build on existing literature to develop tools for assessing and improving organizational readiness for care coordination.